title: Patterns of engagement with the health care system and risk of subsequent hospitalization amongst patients with diabetes.
abstract: BACKGROUND
  Re-hospitalization is common among patients with diabetes, and may be related to aspects of health care use. We sought to determine the association between patterns of health care engagement and risk of subsequent hospitalization within one year of discharge for patients with diabetes.
  
  
  METHODS
  We identified adults with incident diabetes in Alberta, Canada, who had at least one hospitalization following their diabetes diagnosis between January 1, 2004 and March 31, 2011. We used Cox regression to estimate the association between factors related to health care engagement (prior emergency department use, primary care visits, and discharge disposition (i.e. whether the patient left against medical advice)) and the risk of subsequent all-cause hospitalization within one year.
  
  
  RESULTS
  Of the 33,811 adults with diabetes and at least one hospitalization, 11,095 (32.8%) experienced a subsequent all-cause hospitalization within a mean (standard deviation) follow-up time of 0.68 (0.3) years. Compared to patients with no emergency department visits, there was a 4 percent increased risk of a subsequent hospitalization for every emergency department visit occurring prior to the index hospitalization (adjusted Hazard Ratio [HR]: 1.04; 95% CI: 1.03-1.05). Limited and increased use of primary care was also associated with increased risk of a subsequent hospitalization. Compared to patients with 1-4 visits, patients with no visits to a primary care physician (adjusted HR: 1.11; 95% CI: 0.99-1.25) and those with 5-9 visits (adjusted HR: 1.06; 95% CI: 1.00-1.12) were more likely to experience a subsequent hospitalization. Finally, compared to patients discharged home, those leaving against medical advice were more likely to have a subsequent hospitalization (adjusted HR: 1.74; 95% CI: 1.50-2.02) and almost 3 times more likely to have a diabetes-specific subsequent event (adjusted HR: 2.86; 95% CI: 1.82-4.49).
  
  
  CONCLUSIONS
  Patterns of health care use and the circumstances surrounding hospital discharge are associated with an increased risk of subsequent hospitalization among patients with diabetes. Whether these patterns are related to the health care systems ability to manage complex patients within a primary care setting, or to access to primary care services, remains to be determined.
authors.affiliation: Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Canada. brenda.hemmelgarn@albertahealthservices.ca.
authors.forename: Paul E
authors.initials: PE
authors.lastname: Ronksley
authors.forename: Pietro
authors.initials: P
authors.lastname: Ravani
authors.forename: Claudia
authors.initials: C
authors.lastname: Sanmartin
authors.forename: Hude
authors.initials: H
authors.lastname: Quan
authors.forename: Braden
authors.initials: B
authors.lastname: Manns
authors.forename: Marcello
authors.initials: M
authors.lastname: Tonelli
authors.forename: Brenda R
authors.initials: BR
authors.lastname: Hemmelgarn
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000416:Alberta / Q000453:epidemiology; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D003920:Diabetes Mellitus / Q000628:therapy*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000706:statistics & numerical data; D016016:Proportional Hazards Models; D012307:Risk Factors